ICU Form III

<VISA INFORMATION SHEET FOR APPLICATION FOR CERTIFICATE OF ELIGIBILITY1/2> EAG

a. Name: [ / 　　 　　]Family 　　 Given

b. Date of birth (yyyy/mm/dd): / /

c. Gender: □Male 　　□Female d. Marital status: □Single □Married

e. Place of birth: <City or State> <Country>

f. Home town/city: <City> 　　 <State> 　 <Country>

a. Do you hold a valid passport?□ No I am in process of applying for a new passport.□ Yes I have a valid passport.

Do you hold more than one valid passport?□ No□ Yes 　→Name of Countries [ ]

b. Information about the passport you intend to use when you enter Japan:

Nationality:

Passport Number:Date of expiration (yyyy/mm/dd): / /

a. Place to apply for Student Visa : <City> <Country> If undecided, write a location of Japanese Embassy / Consulate closest to your home.

b. Expected Date of Entry into Japan (yyyy/mm/dd): / /

c. Tentative Port of Entry： □Narita Airport 　□Haneda Airport □ Others [ ]

d. Accompanying Persons： □ No 　 □ Yes　→Relationship to applicant [ ]

e. Have you ever visited Japan? （ Transit is not counted. ）

□ No □ Yes → How many times? [ ] time(s)→ Period of your latest entry (from yyyy/mm/dd to yyyy/mm/dd):

from / / to / / f. Criminal record in Japan or overseas:

□ No □ Yes → Detail [ ] Have you ever departed Japan by deportation or departure order?

□ No □ Yes → How many times? [ ] time(s)→ The latest departure by deportation(yyyy/mm/dd): / /

VISA INFORMATION SHEET FORAPPLICATION FOR CERTIFICATE OF ELIGIBILITY

If you are residing abroad and are not eligible for obtaining a Japanese passport, you need to apply for “Certificate of Eligibility” to ensure your status of residence in Japan as a student. Please fill out this form and send with the application form for admissions. Please note that the information you write on this form is to be used for Application for Certificate of Eligibility prescribed by the Ministry of Justice. Those who are already living in Japan and have a valid Residence Card until March 31, 2018 are NOT required to submit this form.

1. PERSONAL INFORMATION

2. PASSPORT INFORMATION

3. JAPAN ENTRY INFORMATION

Please note that COE will be sent to you in early March to mid March.

g.

IMPORTANT!!:Those who have Japanese nationality, including those who currently do not possess a Japanese passport but have eligibility for applying for it, must enter with a Japanese passport.

ICU Form III

<VISA INFORMATION SHEET FOR APPLICATION FOR CERTIFICATE OF ELIGIBILITY2/2> EAG

Name:

Relationship to applicant:

Nationality:

Date of Birth (yyyy/mm/dd): / /

Name of Company, School, etc.:

Intend to reside with applicant? □Yes 　　　　　□No

Status of Residence*：

Residence Card Number/ Special Permanent Resident Certificate Number:

a. Total Period of Education (cumulative years of education since elementary school to the present): years

b. Current Status： □Graduated □ In School □ Withdrew □Leave of Absence

c. Degree（Expected)： □Doctor 　　 　□Master 　　 　□Bachelor

d. Date of Graduation or Expected Graduation (yyyy/mm)： /

　　 □Received □Expected to Receive

e. Name of School Prior to the Enrollment in ICU:

□

□

□

Siganture

E-mail

Phone

Date (yyyy/mm/dd)

6. Other Items to be Submitted to ICU for Application for Certificate of Eligibility　　 *Check when ready.

*i.e. Japanese National, Non-Japanese Permanent Resident, Diplomat, Official, Professor, Artist, Religious Activities,Journalist, Investor/Business Manager, Legal/Accounting Services, Medical Services, Researcher, Instructor, Engineer,Specialist in Humanities/International Services, Intra-company Transferee, Entertainer, Skilled Labor, Cultural Activities,Student, Trainee, Dependent, Designated Activities, Spouse or Child of Japanese National, Spouse or Child ofPermanent Resident, Long Term Resident.

4. FAMILY IN JAPAN [Father, Mother, Spouse, Child, Brother, etc] or co-residents if any:If not applicable, go to #5.

5. EDUCATION

I hereby declare that the statements given here are true and correct and understand that the information providedhere is to be released to Tokyo Regional Immigration Bureau through the proxy, International Christian University,for my application for Certificate of Eligibility.

A copy of passport (biography page) with all information legible, and a clear photo image. →If you are currently in process of applying for a new passport, please send a copy as soon as it becomes available.ONE passport photograph facing front, no headgear. 4 cm in height x 3 cm in width, with your name written on the back. With digitalized photos, the quality must be high (i.e. no visible dots can appear in the image, must be produced using photo paper).

A copy of the Residence Card (Only those who are already living in Japan but do NOT have a valid Residence Card until March 31, 2018)

Application will be rejected if the above standards are not adhered.

Attach your photo with apaper clip. / /

Confirmation of Financial Resources form (Form IV) & evidence of funds (Copies are not accepted)□